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Chapter 7: Sleep-Related Movement Disorders

A Case Study in Restless Leg Syndrome (RLS)

Darlene is a 34-year-old nurse who was referred to the sleep disorders center for insomnia, non-restorative sleep, and a feeling of malaise throughout the day.

Patient History and Examination: Darlene’s sleep problems began during late adolescence and started with difficulty falling asleep. She also developed frequent awakenings throughout the night. Although she complained of aches and irritating discomfort in her legs during the evening, the sleep disturbance had initially been ascribed to stress (especially during nursing school) and to her shiftwork. (Stress and shiftwork have recently abated since Darlene took a daytime job.)

Relaxation training, sleep health habits, and prescription hypnotics have been unsuccessful at improving her sleep.

Further investigation was conducted into Darlene’s leg discomforts. She reported that the sensation is an urgency to move her legs in order to alleviate discomfort. Moving her legs provides partial and temporary relief of the discomfort. The sensations are worse when she is at rest (i.e., lying or sitting down), and later in the day; they occur mainly during the evening and during the nighttime. When she takes a nap during the day, she is rarely bothered by these sensations.

Past Medical History: Darlene suffered from “growing pains” as a child, which she described as leg aches and a feeling that her legs were only loosely attached to her body and were occasionally hard to control. Before admission to the sleep center, Darlene was on temazepam 30 mg hs, which was largely ineffective.

Social History: Darlene drinks 5 cups of strong coffee throughout the day to stay awake. She feels too exhausted to exercise. She has been happily married for 10 years and has 2 daughters, ages 8 and 6.

Family History: None relevant.

Review of sleep pattern: Prior to treatment, Darlene typically went to bed around 11:00 PM and usually fell asleep within 30 minutes, unless her restless legs were particularly severe. In such cases, she had to get up repeatedly “to walk off her legs;” at such times, sleep onset might be delayed for 2-3 hours. Once asleep, Darlene typically woke up 3-5 times per night with achy legs. Before they were married, Darlene’s boyfriend refused to sleep in her bed because she moved so much.

Evaluation and Diagnosis: A polysomnographic exam documented the existence of periodic limb movements during sleep (PLMS) and ruled out other sleep disorders, including Obstructive Sleep Apnea Syndrome (OSAS). In approximately 70% of Darlene’s PLMS, she experienced short arousals from sleep. On the basis of her history, Darlene was diagnosed with Restless Legs Syndrome.

Treatment: Sleep health measures were started: A gradual but almost total decrease in caffeine intake was requested, along with a leg exercise regime to be completed almost daily. The bedroom clock was removed. These measures did little to decrease Darlene’s RLS symptoms, however.

To determine whether Darlene’s RLS could be associated with her iron deficiency, her serum ferritin level was measured and found to be 24 ng/mL. Upon inquiry, no organic reason for her iron deficiency was found except for her frequent blood donations. She was advised to stop the donations and to take iron supplements. When her ferritin levels rose above 50 ng/mL, Darlene’s RLS symptoms stopped.